We read with interest the article by Roayaie et al. reporting on resection of hepatocellular carcinoma (HCC) ≤2 cm in two Western centers.1 This elegant study shows that excellent results (e.g., up to 80% 5-year survival) can be achieved with adequate surgical resection in selected patients with small HCC. These results are in line with the study from our group published this year in HEPATOLOGY concerning potentially transplantable patients who were resected first in a strategy of salvage transplantation in cases of recurrence.2 In the context of organ shortage, we fully agree with the conclusion that resection should continue to be a first-line option in patients with preserved liver function.1 In addition to classical tumor factors, these two studies confirm that nonanatomic resection and presence of cirrhosis were associated with a higher risk of recurrence. In our series, for instance, 64% of the patients who did not experience recurrence after resection had stage 3 fibrosis. The feasibility of anatomic resection, which was independently associated with less recurrence, as well as postoperative morbidity, obviously depends upon the extent of underlying fibrosis. Although Roayaie et al. have shown that advances in the management of HCC could come from the underlying liver parenchyma, they do not mention the usefulness of preoperative biopsy of nontumorous liver parenchyma, to better select the optimal candidates for resection. The importance of nontumorous parenchyma is illustrated by the finding by the same group that gene expression signatures in the adjacent liver parenchyma, but not in the tumor, were highly correlated to recurrence and survival after resection.3
Overall, these data strongly suggest that in addition to tumor status, careful assessment of nontumorous liver parenchyma with preoperative biopsy of the nontumorous parenchyma should be incorporated in the decision-making of patients with small HCC who are potential candidates for resection.